Reframing the debate

Introduction

There is substantial controversy surrounding the administration of the human papillomavirus vaccine for young girls in publicly funded religious school boards. Vaccination programs delivered by regional jurisdictions have had tremendous success in preventing contagious diseases in the past, but this vaccine’s association to a sexually transmitted infection has caused certain religious authorities to reframe the issue as a moral one, rather than purely health-related.[1] Many religious and conservative groups claim the vaccine encourages sexual activity and promiscuity among youth. Yet, persistent human papillomavirus infection is the single biggest risk factor for the development of high-grade cell abnormality, and ultimately cervical cancer.[2] However, provincially-funded vaccination programs have been banned in certain publicly funded Catholic school boards across Canada. This has raised very serious questions of accountability regarding their decision-making process, as well as the impact of withholding a vaccine that could safely prevent girls from developing cervical cancer.[3]

Background

The human papillomavirus vaccine Gardasil was authorized for marketing in Canada on July 10, 2006 for females age 9-26.[4] (Please refer to Cervical Cancer Screening on our site.) Since that time, the federal government has devoted given $300 million to assist the provinces in delivering publicly funded human papillomavirus vaccination programs to reduce cervical cancer-related deaths. Its use is now being advocated for boys as well (please refer to Boys left out), although there are currently no school-based immunization programs covering both genders.

In Canada, decisions on immunization safety are made by the National Advisory Committee on Immunization as well as the Canadian Immunization Committee. The latter organization is comprised of federal and provincial health representatives to promote the harmonization of immunization programs in Canada as well as provide advice on implementation policies to meet national goals and targets.[5] However, publicly funded immunization programs are primarily a provincial responsibility. Since provinces do not have the same access to revenue streams as their federal counterpart, any federal funding assistance is conditional with respect to how those funds are used. In the case of the HPV vaccine, federal intervention also allowed for bulk purchasing at cheaper rates to maximize the vaccine’s reach.[6]

Provinces still retain a degree of flexibility in deciding how to implement the human papillomavirus vaccination programs in order to target the high risk groups who need it most. In Ontario for example, the program is locally administered by its 36 public health departments at schools, precisely because this was the optimal choice.[7] However, the school boards are responsible for supervising the operation and financial management of these funds.[8] The refusal by some publicly funded Catholic school boards to allow clinics into their schools has severely diminished not only the most efficient way to reach children, but according to the Joint National Advisory Committee on Immunization and the Canadian Immunization Committee workgroup, the most cost-effective way of administering the programs. Refusing conditional funding places heavy financial pressure on the provinces not only to find alternate and more expensive means of vaccinating at-risk youth, but also to deal with the long term fallout from more intensive cervical cancer-related treatment.

In Ontario, the Northwest Territories and Alberta, thousands of girls go unvaccinated every year because of resistance from religious school boards in those provinces.[9] For example, the vaccine is currently banned by Calgary Catholic School Board trustees. When children in Calgary were initially sent home with vaccination forms from Alberta Health Services, they were given an additional letter from six bishops warning of promiscuity and pre-marital sex.[10] This letter manipulates the intended effects of the vaccine.[11] These same letters have been reproduced by the Ontario Council of Catholic Bishops, although the program has not been banned outright by most school boards.

Analysis

Previous school-based programs have demonstrated tremendous success in immunizing children against diseases. Prior to the measles vaccine, 500,000 cases were diagnosed in Canada with this virus.[12] In 2000, only 81 cases were reported.[13] Hepatitis-B vaccinations have also successfully reached 86% of students.[14] That being said, there are no mandatory school immunization programs in Canada with the exception of some jurisdictions that require certain vaccinations prior to enrolment. None of these include human papillomavirus vaccines. However, when mandatory vaccinations do exist, they generally have broad explicit provisions for exemptions.[15] This begs the question as to why the HPV vaccine is being banned in some school boards outright.

Opponents view mandatory human papillomavirus vaccination as an attempt by government to force a child to undergo an intervention that may be irreconcilable with parental values and beliefs concerning sexual behaviour.[16] Concerns over changes in sexuality and promiscuity tended to be raised more prominently in the media “after the fact” due to responses by Catholic school boards.[17]

In the Northwest Territories, there was a 5-2 decision against the human papillomavirus vaccination by the Catholic School Board on the grounds that they did not have enough information on the vaccine. According to the board, they did not think that the vaccine prevented cervical cancer and that the messages about the relation between the human papillomavirus and cancer were simply scare tactics.[18]

Alberta’s statistics shows an alarming contrast between its two largest cities. In 2009, the percentage of girls who received the vaccine in Edmonton Catholic schools allowing the provincial health program was 70%; in Calgary, where the vaccine is currently banned by Calgary Catholic School Board, the vaccination rate was only 18.9%.[19] Ontario’s provincial vaccination rate for girls is about 50% when publicly funded Catholic schools are included in the school population.[20] Ontario Catholic schools required parental permission as a means of deferring responsibility for the vaccine’s supposed “social side-effects.” This pales in comparison to other regions in Canada, such as Québec and Atlantic Canada, which boast vaccination rates of 83 % and 88% respectively.[21] No province in Atlantic Canada currently funds Catholic school boards; and while Québec provides partial funding, it does so only via rigorous conditions with respect to provincial guidelines on curriculum and inspection.[22]

Apprehension regarding information on the vaccine when it was initially released does stand as reasonable grounds for concern. In Canada, the human papillomavirus vaccine was actively marketed by the manufacturer through direct consumer advertising and public awareness campaigns. However, the speed of its release may have backfired in that some school boards expressed concerns about where the advertising was coming from.[23] Efforts by the Ontario government to lend reassurance to the vaccine’s safety and effectiveness were disrupted by the 2007 election, where campaign rules placed certain restrictions on its communications branch during the campaign period.[24] Yet, acceptance levels were still rated around 74-89% in favour of vaccination.[25]

Positions

Both Health Canada and the Canadian Paediatric Society strongly encourage young women to receive the human papillomavirus vaccine.[26] The vaccine is also heavily endorsed by the Society of Obstetricians and Gynecologists of Canada.

In Ontario, the Conference of Catholic Bishops, while not banning the vaccine outright, have made non-scientific linkages with respect to the program and sexuality, and declared there to be insufficient knowledge about the human papillomavirus vaccine.[27] In reality, there is more confusion among youth with respect to what the human papillomavirus vaccine actually protects against, but not in terms of its effectiveness or safety.[28] The only publicly funded board in Ontario to outright ban the program is the Huron Catholic School Board, which claims that vaccinating girls against a sexually transmitted infection constitutes the “hypocrisy” in an education system dedicated to teaching.[29] In other publicly funded religious schools, Ontario provincial health units met with such resistance in spite of their right to enter school premises that they were forced to contact the children’s homes individually to even inform them of their eligibility for the vaccine.[30]

The Calgary Catholic School Board Trustees have banned the vaccine outright based on the “spiritual decision” from their local bishop rather than health professionals.[31] The concern with respect to this position is that the board delegated its formal decision-making responsibility to a non-elected official without expertise in evidence-based medicine or public health.[32] HPV Calgary, a pro-vaccine citizens’ coalition, advocates for the vaccine, arguing that the church is endangering thousands of lives.[33] While private academic institutions have the complete right to adopt any form of decision-making process, there are accountability concerns regarding how both policy and financial decisions are reached within publicly funded school boards. For example, the Joint National Advisory Committee on Immunization and the Canadian Immunization Committee workgroup had to provide an analytic framework including human papillomavirus characteristics and burden, vaccine characteristics, alternate immunization strategies, social and economic costs and benefits to vaccination, feasibility and acceptability of vaccination.[34] Most importantly, they were obligated to monitor and evaluate the vaccine every two years to ensure there were no significant side effects.[35]

It is very interesting to note that neither the Vatican nor the Canadian Conference of Catholic Bishops actually ban the vaccine. This speaks to how localized this issue is in certain areas of the country. However, reframing the debate from a health to a moral issue should be of primary concern to all stakeholders. Discussion is difficult when one tries to justify health issues with terminology that either doesn’t apply or improperly captures the idea behind causality and variables.

Discussion

Persistent cervical infection with high-risk human papillomavirus strains is necessary for the development of cervical cancer, and nearly 100% of cervical cancers test positive for the human papillomavirus.[36] The risk of the human papillomavirus is highest in adolescent girls due to the cervical tissue changing so rapidly during maturation.[37] While cervical cancer screening practices have been very effective, they are not perfect. There is particular difficulty in detecting adenocarcinoma through conventional screening methods. Adenocarcinoma is a more lethal, rapidly progressive form of cervical cancer associated with human papillomavirus Types 16 + 18, two of the primary strains that the vaccine directly protects against.[38]

The value of human papillomavirus vaccination declines if a woman has already been infected prior to vaccination (E164). Hence, a funded, cost-effective vaccine should be administered when immune systems can benefit the most.[39] Even if a daughter chooses to follow the principles of abstinence, this does not take into account the possibility of sexual assault over her lifetime; nor is she immune to a spouse who was not abstinent and may already be infected with the human papillomavirus.[40] The virus is as much a threat to boys as girls, and can lead to penile cancer in men, as well as anal and throat cancers across both genders. The response rate of this effective vaccine has been mirrored by a reduction in the need for colposcopy and cervical excisions, the associated trauma and anxiety of these procedures, and the potential treatment of lesions that would never have progressed to cervical cancer.[41] From a structural perspective, this can relieve pressure off a health care system soon to be affected by an aging demographic.

There are significant constraints against alternate means of vaccinating children. The human papillomavirus vaccine actually requires three sessions of shots to be delivered over a period of half a year. School vaccinations provide mass protection administered in a way which removes a lot of the time and scheduling restraints for families if they had to visit clinics independently.[42] This is also important for children living in rural communities, who are already faced with a lack of clinics in close proximity.

The benefits of school-based programs also include peer support at the time of immunization, and reductions in socio-economic gradients in vaccination coverage.[43] Children at the highest risk of developing the human papillomavirus are those from lower socio-economic backgrounds, and are therefore less likely to be vaccinated if not in schools.[44] Parents of low-income families may be working multiple jobs and may face greater difficulty in transporting their child to a health clinic. Education-wise, children from a lower socioeconomic background may not have the same access to the information with respect to what the vaccine specifically prevents, and they may forego safe practices if they become sexually active.[45]

It is interesting to note that there has been discussion about this issue by various bio-ethical and religious medical organizations. Pro-vaccine advocates argue that from an ethical perspective, Catholic health laws do not prohibit the human papillomavirus vaccine on the following two grounds:[46]

DOUBLE EFFECT: Neither the act of vaccination nor the prevention of infection is intrinsically evil. The benefit (absence of infection) is not achieved by the means of harm (sexual immorality). The established and evidenced beneficial effect of cervical cancer prevention is far greater than unsubstantiated fears of increased promiscuity.[47]

LEGITIMATE COOPERATION PRINCIPLE: When an action involves more than one person, it is unethical to cooperate formally with that action if it is immoral. However, it can be a moral duty for Catholics to participate individually in such an act if the intention of doing so is to produce a good effect and to avoid or reduce greater harms.[48] Therefore, even if one feels vaccines interfere with the message of abstinence, the goal of the health practitioner is to reduce the occurrence of the human papillomavirus and ultimately to reduce harm.[49]

Parents

Factors that affect the intentions of parents on this issue are crucial to promoting the highest possible rate of human papillomavirus vaccination for all young people.[50] Parents may not perceive HPV as an immediate threat to their children, and therefore may not throw their full support behind the recommended age for vaccination.[51] Educational intervention has proven effective for parents initially apprehensive about their daughters receiving the vaccine. The educational material often consists of information discussing human papillomavirus prevalence, its severity, route of transmission, diagnosis and subsequent treatment.[52] However, more work needs to be done to emphasize the linkages between the human papillomavirus and cervical cancer. Further discussion regarding the benefits and limitations of the vaccine is also necessary. Most parents were actually receptive to vaccinating their daughters because they knew that they were not going to be able to control every single decision their child makes, even under the best of circumstances.[53]

Conclusion

There has been little public debate about whether publicly funded school boards should be “entitled” to refuse admission to public health officials.[54] School-based vaccine delivery in contrast to physician delivery is regarded as the optimal platform to achieve high coverage for youth and adolescent immunization.[55] Provincial laws exist to allow for exemptions for the vaccine; however, this does not merit banning these programs outright. To do so does a disservice to the largest groups of girls at risk of developing cervical cancer. Publicly-funded Catholic schools receive millions of dollars of annual provincial funding, and should not ignore the socio-economic and health implications of their actions on the health care system.[56] This is not a moral issue; this is a health and accountability issue, first and foremost. As such, the state has an important role to play in ensuring that high risk groups are provided with access to the benefits of the human papillomavirus vaccine in order to protect their health.

Regardless of the school board’s decision, it’s important that parents receive accurate and objective information in order to understand the potential health benefits of vaccination and the value of continued screening.

The National Advisory Committee on Immunization (NACI) is a national committee of recognized experts in the fields of pediatrics, infectious diseases, immunology, medical microbiology, internal medicine and public health. NACI makes recommendations for the use of vaccines currently or newly approved for use in humans in Canada, including the identification of groups at risk for vaccine-preventable disease for whom vaccine programs should be targeted. All NACI recommendations on vaccine use in Canada are published every four years in the Canadian Immunization Guide. You can also refer to http://www.phac-aspc.gc.ca/publicat/cig-gci/index-eng.php

The Federation of Medical Women of Canada’s statement promoting the use of HPV vaccines can be accessed above. They speak to both general recommendations for females at risk of cervical cancer as well as now recommending that young males be vaccinated against the HPV virus, which does not discriminate by gender.

The Society of Obstetricians and Gynaecologists of Canada’s mission is to “promote excellence in the practice of obstetrics and gynaecology and to advance the health of women through leadership, advocacy, collaboration, outreach and education”. It frequently releases easily accessible publications and guidelines advocating for best practices in cervical cancer-related policy.